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Executive Summary
Inclusion Criteria
Age > 3 months with confirmed
appendicitis by the surgical team
requiring acute or delayed
appendectomy
Citation Information
Exclusion Criteria
Age < 3 months and patients who
do not have a confirmed
appendicitis diagnosis by the
surgical team
Off
Pathway
No
Non-Operative Appendicitis
Urgent Appendectomy
Surgical Team
Surgical Team
severe beta
beta lactum
lactum allergy
allergy then
then
IfIf severe
ciprofloxacin ++ metronidazole
metronidazole
ciproflaxacin
Appendicitis v.1.2
Care in the OR
IVIV
Antibiotics
surgical
site
profolaxsis
Antibiotics
forfor
surgical
site
prophylaxis
Antibiotics need to be given less than one hour prior to incision
If no antibiotics have been given in less than one hour prior to incision, then
cefoxitin
gentimicin
If severe beta lactam allergy then give clindamycin + gentamicin
A Anesthesia to assess and establish good IV access
OR Findings
Complicated vs Uncomplicated Appendicitis:
Perforated
Gangrenous
Suppurative
Peritonitis
Abscess
Yes
Complicated Appendicitis
Post Operative Care:
NG Tube if distended or vomiting
NPO
Advance diet as tolerated
IV Fluids
Pain Management
Monitoring
IV Antibiotics for at least 72 hours
& METRONIDAZOLE
CEFTRIAXONE
ceftriaxone + metronidazole
severe beta
beta lactam
lactam allergy
allergy then
IfIf severe
ciproflaxacin + metronidazole
ciprofloxacin
No
Uncomplicated Appendicitis
Post Operative Care:
Discharge Criteria
Discharge Readiness Assessment:
Beginning at POD#3, continuing daily until post op/
discharge criteria are met:
IF
Afebrile (T<38C)
Tolerating Diet
Pain well managed
No sign of wound
infection
THEN
Afebrile (T<38C)
Tolerating Diet
No sign of wound infection
Pain is controlled
Check CBC
differential
If CBC/Differential
NORMAL Transition to
PO Antibiotics and
Discharge
If CBC/Differential
ABNORMAL Continue IV
antibiotics and reassess
daily until patient meets
discharge criteria or POD
#7
Transition to PO antibiotics
IV + PO antibiotics = 7days Total
PO Augmentin
If severe beta lactam allergy transition to
ciprofloxacin + metronidazole
If patient has
not met
discharge
criteria by POD
#7 then
reassess
Discharge Criteria
CT Scan
Labs CBC +
differential
CRP
BUN/Creatinine
AST
ALT
Off
Pathway
Additional Information
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Additional Information
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Non-Operative Appendectomy:
Some of the these patients may have an appendectomy during their initial
hospitalization and then they would go onto the appropriate postoperative
care pathway as determine by the findings at the time of operation.
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Urgent Appendectomy:
Most of these procedures will be within a few hours and almost all will be
within 12-24 hours of the decision for operation.
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Additional Information
Ceftriaxone & Metronidazole
For patients with diagnosis of appendicitis empiric treatment with broad spectrum antibiotics active against enteric
gram-negative aerobic and facultative bacilli, enteric gram -positive streptococci and obligate anaerobic bacilli is
indicated.*
Acceptable broad-spectrum antibiotic regimens for children with complicated intra -abdominal infection include*
1. Aminoglycoside based regimen (ex. triple antibiotics gentamicin, ampicillin and metronidazole
2. Carbapenem (ex. Meropenem)
3. Beta-lactam/beta-lactamase-inhibitor combination (ex. Piperacillin-tazobactam)
4. Advanced generation cephalosporin (ex. Ceftriaxone) and metronidazole
o is easy to transition to home treatment of oral metronidazole and once -a-day IV ceftriaxone
*Solomkin JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by th e Surgical
Infection Society and the Infectious Disease Society of America. Clinical Infectious Diseases 2010; 50:133-164
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OR/Post-Op
Patients on the Non-Operative Appendectomy pathway will go to the floor or ICU based on
their clinical condition.
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If the patient has a history of severe beta lactam allergy then the next
antibiotic choice is intravenous ciprofloxacin and metronidazole.
*Solomkin JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by th e
Surgical Infection Society and the Infectious Disease Society of America. Clinical Infectious Diseases 2010; 50:133-164
*Adefurin A. Ciprofloxacin safety in pediatrics: a systematic review
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OR/Post-Op
Additional Information
If the patient has not received broad spectrum antibiotics for treatment of appendicitis (as outlined
in previous pathway steps) or if these antibiotics have been given more than one hour from the
time of incision then an additional dose of antibiotics (either cefoxitin or in patients with severe
beta lactam allergies, gentamicin and clindamycin) should be given in the operating room
immediately prior to the incision.2
For SSI prophylaxis the dose of cefoxitin in 40 mg/kg up to a maximum of 2 grams and the dose
should be repeated every 2 hours during the operation.3
1. Lee SL, et al. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes an d
Clinical Trials Committee Systematic Review. J Pediatr Surg 2010 45:2181-2185.
2. Solomkin JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the
Surgical Infection Society and the Infectious Disease Society of America. Clinical Infectious Diseases 2010; 50:133-164
3. Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195283.
If further antibiotic therapy is indicated postoperatively for patients with severe beta
lactam allergy then ciprofloxacin and metronidazole will be used.
Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst
Pharm. 2013; 70:195-283.
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OR/Post-Op
Additional Information
Issues
Patients with acute appendicitis often have small PIVs placed upon arrival in the ER.
Small antecubital PIVs are uncomfortable for patients and have a tendency to infiltrate
more quickly than PIVs placed in other locations.
Since PICC lines are no longer routinely placed in patients with complicated
appendicitis, it is optimal to have a comfortable PIV that will last for the duration of
postoperative antibiotic treatment.
This should link to page 15 which defines complicated vs uncomplicated appendicitis.
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OR/Post-Op
Additional Information
OR Findings:
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OR/Post-Op
Additional Information
All patients with complicated appendicitis will receive a total of 7 days of IV+PO
antibiotics.
On or after POD #3 when patient is well on exam (afebrile, tolerating a diet, with no
signs of wound infection and with only expected pain and tenderness) then CBC with
diff will be checked.
If CBC and diff are normal (based on the normal ranges for age as described in CIS)
then the patient can be transitioned to PO antibiotics and if PO antibiotics are
tolerated then discharged home.
If CBC and diff are abnormal then patient will continue to receive IV antibiotics and
patient will be reassessed daily.
Assessment at 7 days:
If after 7 days of treatment the patient is not ready for discharge home; ie if they are
febrile, not tolerating a diet, have signs of wound infection or more than expected
pain and tenderness, or an abnormal WBC or diff, then they will be reassessed and
further treatment individualized.
For the patient who is not ready for discharge on POD#7 blood tests should be
obtained
CBC and diff and CRP to assess on-going inflammation and infection
BUN/Creatinine and transaminases to assess possible drug side effects
For the patient who is not ready for discharge on POD#7 abdominal imaging (CT
scan) should be considered either at this time or at a defined time in the near future
to evaluate for possible intra-abdominal abscess (i.e., inadequate source control)
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OR/Post-Op
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Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Childrens Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
health care decision.
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Bibliography
Search Methods, Appendectomy, Clinical Standard Work
Studies were identified by searching electronic databases using search strategies developed and
executed by a medical librarian, Susan Klawansky. Searches were performed in November 2012 in
the following databases on the Ovid platform: Medline and Cochrane Database of Systematic
Reviews; elsewhere: Embase, Clinical Evidence, National Guideline Clearinghouse and TRIP. Retrieval
was limited to 2002 to current, humans, and English language. In Medline and Embase, appropriate
Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text
words, and the search strategy was adapted for other databases as appropriate. Concepts searched
were appendectomy, intraabdominal infection, appendicitis or appendix. All retrieval was further
limited to certain evidence categories, such as relevant publication types, index terms for study types
and other similar limits.
Susan Klawansky, MLS, AHIP
March 27, 2013
Identification
114 records identified through
database searching
Screening
2 records after duplicates removed
62 records excluded
Elgibility
Included
10 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
To Bibliography, Pg 1
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Bibliography
Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ, 2010 American Pediatric Surgical Association Outcomes and
Clinical Trials,Committee. Antibiotics and appendicitis in the pediatric population: An american pediatric surgical
association outcomes and clinical trials committee systematic review. J Pediatr Surg [Appendectomy].
2010;45(11):2181-2185.
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in
adults and children: Guidelines by the surgical infection society and the infectious diseases society of america. Clin
Infect Dis [Appendectomy]. 2010;50(2):133-164.
Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intraabdominal infections. Clin Infect Dis [Appendectomy]. 2003;37(8):997-1005
To Bibliography, Pg 2
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Bibliography
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Appendicitis Citation
Title: Appendicitis Pathway
Authors:
Seattle Childrens Hospital
Dan Ledbetter
Suzan Mazor
Elaine Beardsley
Vincent Hsieh
Jennifer Magin
Erin Moriarty
Mike Leu
Jean Popalisky
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